Commonwealth of Pennsylvania
DEPARTMENT OF EDUCATION
333 Market St., Harrisburg, PA 17126-0333
INSTRUCTIONAL I TO INSTRUCTIONAL II ASSESSMENT FORM
Applicant’s Last Name
First
Middle
Positions(s) of Employee
District/IU
School
Evaluator
Interview/Conference Date
Directions:
This form is used after having reviewed 6 satisfactory semi-annual employee evaluations of the
teacher’s performance. All categories in this form must be assessed as well as all sources of evidence provided
by the teacher. The evaluator should bear in mind the aspects of teaching for each category and refer to the
rubric language. If applicable, record commendations. Finally, assign an overall assessment, sign the form and
gain Superintendent’s review and signature.
Category I: Planning/Preparation--Through their knowledge of content and pedagogy skills in planning and preparation, teachers make
plans and set goals based on the content to be learned, their knowledge of students and their instructional context. Category I reviews:
Knowledge of Content and Pedagogy, Knowledge of Pennsylvania Academic Standards, Knowledge of Students, Selecting Instructional
Goals, Designing Coherent Instruction, Assessing Student Learning, Knowledge of Resources, Materials and Technology.
Teacher’s performance demonstrates:
o In-depth and thorough knowledge of content and pedagogy
o In-depth and thorough knowledge of Pennsylvania’s Academic Standards
o In-depth and thorough knowledge of students and how to use this knowledge to inform instruction
o Clear and appropriate instructional goals that reflect content standards and high expectations for students
o Thorough awareness of resources, materials, and technology available through the school or district or professional organizations
o Appropriate and coherent instructional design in which plans for all elements are completely aligned with the instructional goals, have a clear
sequence, and include adaptations for individual student needs
o Appropriate and clear assessments of student learning completely aligned to the instructional goals, and adapted as required for student needs
Sources of Evidence (Check all that apply and include dates, types/titles and number)



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Lesson/Unit Plans
Resources/Material/Technology
Assessment Materials
Information About Students

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Teacher Conferences/Interviews
Classroom Observations
Teacher Resource Documents
Other
Assessment of Category I Factors (Discussion)
PDE-427
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Commonwealth of Pennsylvania
DEPARTMENT OF EDUCATION
333 Market St., Harrisburg, PA 17126-0333
Category II: Classroom Environment --Teachers establish and maintain a purposeful and equitable environment for learning, in which
students feel safe, valued, and respected by instituting routines and setting clear expectations for student behavior. Category II reviews:
Teacher Interaction with Students, Establishment of a Learning Environment, Student Interaction.
Teacher’s performance demonstrates:
o
o
o
o
o
o
High and clear expectations for student achievement in a challenging and dynamic learning environment, with value placed on high quality
student work
Significant attention to equitable learning opportunities for students
Appropriate and highly respectful interactions between teacher and students and among students
Highly effective classroom routines and procedures resulting in effective use of instructional time
Clear standards of conduct and highly effective and preventive management of student behavior
Safe and skillful organization of physical space, to the extent it is under the control of the teacher, that provides accessibility to
learning and to the use of resources, materials, and technology
Sources of Evidence (Check all that apply and include dates, types/titles, and number)
 Classroom Observations
 Visual Technology
 Informal Observations/Visits
 Resources/Materials/Technology/Space
 Teacher Conferences/Interviews
 Other
Assessment of Category II Factors (Discussion)
Category III: Instructional Delivery --Teachers, through their knowledge of content and their skill in delivering instruction, engage
students in learning by using a variety of instructional strategies. Category III reviews: Communications, Questioning and Discussion
Techniques, Engaging Students in Learning, Providing Feedback, Demonstrating Flexibility and Responsiveness.
Teacher’s performance demonstrates:
o
o
o
o
o
o
Clear and appropriate communication of procedures and high-quality explanations of the content
Highly effective use of different levels of questioning and discussion strategies that encourage most, if not all, students to participate
High-level engagement of students in learning and appropriate pacing of instruction
Equitable, accurate, and constructive feedback to students on their learning
Informed and appropriate use of formal and informal assessments to meet learning goals and to monitor student learning
High degree of flexibility and responsiveness in meeting the learning needs of students
Sources of Evidence (Check all that apply and include dates, types/titles, or number)




Classroom Observations
Informal Observations/Visits
Assessment Materials
Teacher Conferences/Interviews




Student Assignment Worksheets
Student Work
Instructional Resources/Materials/Technology
Other
Assessment of Category III Factors (Discussion)
PDE-427
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Commonwealth of Pennsylvania
DEPARTMENT OF EDUCATION
333 Market St., Harrisburg, PA 17126-0333
Category IV: Professionalism--Professionalism is demonstrated through qualities that characterize a professional person in aspects
occurring in and beyond the classroom/building. Category IV reviews: Maintaining Clear and Accurate Records, Communication with
Families and Students, Contributing to School and District, Developing Professionalism.
Teacher’s performance demonstrates:
o Efficient and effective system for maintaining accurate and complete records consistent with school or district guidelines
o Effective communication with families regarding student needs and development
o Frequent participation in professional development opportunities, consistent application of new learning in the classroom, and sharing of
learning with colleagues
o Full commitment to professional standards
o Full and active compliance with school and district policies
o Perceptive reflection on teaching and learning and use of reflection to in future instruction planning
o Full Knowledge of Professional Code of Conduct
Sources of Evidence (Check all that apply and include dates, types/titles, and number)


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
Teacher Conferences/Interviews
Teacher Reflection
Observations/Visual Technology
Artifacts: Interaction with Family
Student Records/Grade Book




Progress Reports/Report Cards
Parent/School/Community Feedback
Artifacts: Professional Development/
Act 48 Documentation
Other
Assessment of Category IV Factors (Discussion)
PDE-427
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Commonwealth of Pennsylvania
DEPARTMENT OF EDUCATION
Teacher’s Name ______________________
333 Market St., Harrisburg, PA 17126-0333
Social Security Number ___________________________
I certify that the before named applicant for the period beginning
and ending
has received an overall
assessment that is:
(month/day/year)
(month/day/year)
_____Satisfactory _____Unsatisfactory
Signature of Principal/Assistant
Principal (Assessor)
Date
Signature of District Superintendent or
I. U. Executive Director
Date
LEA Name
Overall Justification for Assessment
Commendations (optional)
Name of Applicant
Signature of Applicant
Date
PDE-427
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